Birth experience more important than whether baby lives or dies? Here’s a book for you.

I’m looking forward to reviewing the new natural childbirth book by Henci Goer and Amy Romano, CNM when it is release this summer. Thus far I only know the title, and I find it to be quite apt and unintentionally quite revealing.

The book appears to be the next iteration of Goer’s Thinking Women’s Guide to Childbirth. The philosophy behind that title was quite simple: flatter the gullible reader by implying that if you read the book you are “thinking,” as opposed to the rest of the uneducated sheeple who rely on the expertise of their doctors merely because obstetricians have 4 years of college, 4 years of medical school, 4 years of advanced training and thousands of deliveries to their credity. No, “thinking” women trust Henci who has no training in midwifery, no training in obstetrics, no training in statistics and no training in scientific research.

This time Henci has turned away from flattering the reader to conveying her thoughts about birth. The title of the book says is all, Optimal Care in Childbirth: The Case for the Physiological Approach. In one brief phrase, Goer and Romano have managed to convey everything that is wrong with the philosophy of natural childbirth: the fact that more importance is attached to process and the execrable idea that there is an “optimal” way to give birth.

The average reader is not likely to know about the origins of the current NCB catch words “optimal birth” and “physiological birth.” Their history is quite instructive.

As far as I can determine, the phrase “optimal birth” was first popularized by midwives Patricia Murphy and Judith Fullerton in their 2008 paper Development of the Optimality Index as a New Approach to Evaluating Outcomes of Maternity Care.

The optimality index reveals the obsession with process over outcome. As I wrote at the time the paper was published:

… [Murphy and Fullerton] prefer this approach because it deliberately incorporates specific beliefs about what constitutes optimal care. For example, traditional medical studies would consider the birth of a healthy baby to a healthy mother the optimal outcome; the Optimality Index would subtract points from a perfect score because, in their view, having an epidural is a non-optimal outcome.

The following will cause you to lose points on the “optimality index”:

  • NST
  • biophysical profile
  • prescription medication of any kind
  • induction
  • augmentation
  • any medication in labor
  • epidural
  • continuous fetal monitoring
  • directed pushing
  • less than 45° head elevation at birth
  • perineal laceration

But that’s not even the worst part. The worst part is that any of these events are coded as equivalent to:

  • cord prolapse
  • severe pre-eclampsia
  • eclampsia
  • abruption
  • shoulder dystocia
  • intraventricular hemorrhage
  • NEC
  • pneumonia
  • renal failure
  • neonatal seizures
  • perinatal death

So if you have an NST, biophysical profile, induction, any medication in labor, an epidural,continuous fetal monitoring, directed pushing, less than 45° head elevation at birth, a perineal laceration and a LIVE BABY your optimality index is 47.

If you have none of those things and a DEAD BABY, your optimality index is 56.

In other words, Murphy and Fullerton are biological essentialists:

The optimality index has two primary explicit motivations and one primary implicit motivation:

First, it is designed to give far MORE weight to process than to outcome; a perinatal death is equivalent to having an epidural.

Second, it is designed to measure how closely a birth adheres to the values of midwives.

Third, it implicitly dismisses the opinion of the mother by assigning it no value at all.

Ultimately, the optimality index tells us nothing about birth, but a great deal about the midwives who designed it and the midwifery organizations who support it: It does not matter very much to them whether the baby lives or dies. Conforming to the ideals of midwifery is very important to them. The mother’s opinion, needs and desires are meaningless.

The phrase “physiological birth” is similarly indicative of the biological essentialism valued by midwives. As Holly Powell Kennedy, president of the American College of Nurse Midwives explained:

I propose that “normal” is commonly used by midwives as a way to describe a process that counters the common and escalating interventions in many birth settings. A more fitting term might be “physiologic”— that which reflects the innate capacity of a woman’s body to reproduce without intervention—and which most women would be able to achieve when left alone to find their strength, and supported as needed in the process.

There you have it: everything that is wrong with the contemporary midwifery obsession with biological wrapped up in two somewhat clumsy sentences.

As I parsed in my analysis of Kennedy’s claim:

1. “commonly used by midwives”

The definition that counts is the one that midwives select. There are no objective criteria.

2. “counters”

The correct views of midwives are oppositional. Whatever is common in current obstetrical practice is to be opposed. Do common practices save lives? Who cares? It’s about the process, not the outcome.

3. “innate capacity”

What is that supposed to mean? Every woman has the “innate capacity” to get pregnant, but that doesn’t mean that she can. Every women has the “innate capacity” to carry a pregnancy to term but that doesn’t prevent miscarriage. Every woman has the “innate capacity” to have a vaginal delivery, but that doesn’t mean that the baby will fit or that the baby will live through the process.

4. “reproduce without intervention”

Ahh, there’s that obsession with process again. And what’s wrong with interventions anyway? It’s as if Kennedy and other midwives oppose any interventions on the principle that they are inherently bad. No attempt is made to discern if the interventions are helpful or even if they are requested by a woman herself.

5. “most woman would be able to achieve”

Would the baby be alive at the end of this achievement? Would the mother be alive? Kennedy doesn’t say. It’s the process that counts, not the outcome.

The title of Goer and Romano’s new book unwittingly reveals the profoundly unscientific, biased and self aggrandizing nature of contemporary natural childbirth advocacy. NCB is obsessed with labeling women, dividing them into those who give birth following the preapproved directives and those who do not. Natural childbirth advocates are obsessed with process; the outcome is virtually irrelevant.

Goer and Romano have written the perfect book for those who are more concerned with their “experience” than whether the baby lives or dies. No doubt those women will eagerly scoop up the book.

However, if your priority is whether your baby lives or dies, or if you reject the idea that women should be judged by the function of their reproductive organs, you should probably pass on this exercise in biological essentialism.

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